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Chemotherapy for non-Hodgkin lymphoma

Chemotherapy (chemo) is the use of anti-cancer drugs that are usually injected into a vein or taken by mouth. These drugs enter the bloodstream and reach almost all areas of the body, making this treatment very useful for lymphoma.

Doctors give chemo in cycles of a period of treatment, followed by a rest period to allow the body time to recover. Each chemo cycle generally lasts for several weeks. Most chemo treatments are given on an outpatient basis (in the doctor’s office or clinic or hospital outpatient department), but some may require a hospital stay.

Many chemo drugs are useful in treating lymphoma patients. Often, several drugs are combined. The number of drugs, their doses, and the length of treatment depend on the type and stage of the lymphoma. Some of the drugs commonly used to treat lymphoma include (divided into groups by how they work):

Alkylating agents

Cyclophosphamide (Cytoxan®)

Chlorambucil

Bendamustine (Treanda®)

Ifosfamide (Ifex®)

Corticosteroids

Prednisone

Dexamethasone (Decadron®)

Platinum drugs

Cisplatin

Carboplatin

Oxaliplatin

Purine analogs

Fludarabine (Fludara®)

Pentostatin (Nipent®)

Cladribine (2-CdA, Leustatin®)

Anti-metabolites

Cytarabine (ara-C)

Gemcitabine (Gemzar®)

Methotrexate

Pralatrexate (Folotyn®)

Others

Vincristine (Oncovin®)

Doxorubicin (Adriamycin®)

Mitoxantrone

Etoposide (VP-16)

Bleomycin

Often drugs from different groups are used in combination. One of the most common combination of drugs is CHOP. This includes the drugs cyclophosphamide, doxorubicin (which has a chemical name beginning with H), vincristine (Oncovin) and prednisone. Another common combination leaves out doxorubicin and is called CVP.

Chemo is often combined with immunotherapy, especially the monoclonal antibody rituximab (Rituxan®).

Sometimes a patient may get one chemo combination for several cycles and later switch to a different one if the first combination doesn’t seem to be working.

High doses of methotrexate are sometimes used to treat lymphoma in the tissues around the brain and spinal cord and in the spinal fluid (cerebrospinal fluid). More often, though, intrathecal chemo is used.

Intrathecal chemo

Most chemo drugs given systemically (IV or by mouth) cannot penetrate the spinal fluid and tissues around the brain and spinal cord. To treat lymphoma that may have reached these areas, chemo may also be given into the spinal fluid (cerebrospinal fluid). This is called intrathecal chemo. The chemo drugs most often used for intrathecal chemo are methotrexate and cytarabine.

Possible side effects

Chemo drugs attack cells that are dividing quickly, which is why they work against lymphoma cells. But other cells in the body, such as those in the bone marrow, the lining of the mouth and intestines, and the hair follicles, also divide quickly. These cells are also likely to be affected by chemotherapy, which can lead to certain side effects.

The side effects of chemo depend on the type and dose of drugs given and the length of time they are taken. These side effects can include:

Hair loss

Mouth sores

Loss of appetite

Nausea and vomiting

Diarrhea

Low blood cell counts (see below)

These side effects are usually short-term and go away after treatment is finished. If serious side effects occur, the dose of chemo may be reduced or treatment may be delayed.

There are often ways to lessen these side effects. For example, drugs can be given to prevent or reduce nausea and vomiting.

Certain drugs have specific possible side effects. For example, some drugs cause nerve damage (neuropathy), leading to numbness, tingling, or even pain in the hands and feet. Ifosfamide can damage the bladder lining (hemorrhagic cystitis). This can be prevented by giving a drug called mesna with ifosfamide.

Other more serious side effects can occur, depending on the chemo drugs used. Drugs such as doxorubicin can damage the heart. Your doctor may order a test of heart function (like a MUGA scan or echocardiogram) before starting you on one of these drugs. Bleomycin can damage lungs. Doctors often test lung function before starting someone on this drug. Many chemo drugs can affect fertility (the ability to have children). Ask your health care team about what side effects you can expect based on the specific drugs you will receive.

Chemo can also cause side effects that might not occur until years after treatment. For example, in rare cases, people may develop leukemia several years later.

Low blood cell counts: Chemo can cause low blood cell counts because it affects the cells that form blood in the bone marrow. This can lead to:

Increased chance of infections (from low white blood cell counts)

Easy bruising or bleeding (from low blood platelet counts)

Fatigue (from low red blood cell counts)

Infections in people getting chemo can be very serious. Drugs known as growth factors (G-CSF or GM-CSF, for example) are sometimes given to help the white blood cells recover from the effects of chemoand thus reduce the chance of infection. Antibiotics may also be given at the earliest sign of an infection, such as a fever. You also might want to take steps to limit your exposure to germs. These are discussed in our document, Infections in People With Cancer.

If your platelet counts are very low, you may be given drugs or platelet transfusions to help protect against bleeding. Fatigue caused by anemia (very low red blood cell counts) can be treated with drugs or with red blood cell transfusions.

Tumor lysis syndrome is a possible side effect of chemo in patients who had large numbers of lymphoma cells in the body before treatment. It occurs most often with the first cycle of chemo. When the cancer cells are killed, they break open and release their contents into the bloodstream. This can overwhelm the kidneys, which cannot get rid of all of these substances at once. This can lead to the build-up of excess amounts of certain minerals in the blood and even kidney failure. The excess minerals can lead to problems with the heart and nervous system. Doctors work to prevent these problems by giving the patient extra fluids and certain drugs, such as sodium bicarbonate, allopurinol, and rasburicase.

Other drugs used to treat lymphoma

A certain kind of lymphoma of the stomach, mucosa-associated lymphoid tissue (MALT) lymphoma, is linked to infection with the bacterium H. Pylori. Treatment of this infection can cause the lymphoma to go away. This is most often done with a combination of antibiotics along with drugs that turn-off stomach acid called proton pump inhibitors. Examples of proton pump inhibitors, include omeprazole (Prilosec®), lansoprazole (Prevacid®), and esomeprazole (Nexium®).